Priorities

By Eric Crampton 14/04/2014


Free riding kills voluntary contributions in public good games. When individuals see that free-riders are able to do well, and where there’s no way of excluding those free-riders from the benefits of contibutions, or of punishing them, they lower their likelihood of contributing.

And so organ donation rates are pretty low. Donors provide a public good: they increase everyone else’s chance of getting an organ if they need one, but don’t get much out of it other than the knowledge that they’re potentially helping others. Non-donors have equal access to organs should they need one. It’s a sharing club that doesn’t punish members for failing to share; takers gonna take.

Israel’s solution: the Priority Law. Organ donors get extra points in the priority queue should they ever need an organ transplant. And they had to navigate a lot of the same ethical issues that New Zealand faces. Consider the parallels here to certain aspects of Maori concerns around tapu:

Orthodox Israelis opposed to organ harvesting on religious grounds have called the system discriminatory. But Lavee argues that the willingness of those same people to accept donated organs ultimately dissuaded potential donors from participating in the organ pool. “There was a dismay among the Israeli population that there were many, many free riders,” he explained. “Why should people donate if their organs would go to people who would never donate themselves?”

It isn’t a full no-give-no-take system. Instead, donors simply get priority over non-donors. And, beautifully, the families of donors also get priority.

Launched in April 2012, the new Israeli system grants first priority for transplants to living donors and the family members of donors—who, in the event of brain death, make the ultimate decision whether to donate their kin’s organs. Registered donors of three years or more receive second priority; family members of registered donors receive a third tier of priority.

The system confers an advantage to candidates in the same tier of need; it never enables transplant candidates to supersede needier counterparts. Priority can’t catapult Status 2 recipients into the heart-transplant Status 1 list, but it can take them to the top of Status 2. With other organs, like kidneys, where a point system assigns values weighing age, waiting time, and compatibility create a 0 to 18 score, signing up as a donor can add a 1- to 5-point boost.

Results?

In 2013, the first full year of the new system, there were a record number of transplants in Israel; meanwhile, transplants received by Israeli patients abroad fell to a quarter of their 2007 peak. Most of what continues is the result of lawful allocations many nations offer foreign transplant candidates. Another feature of the 2008 Organ Transplant Act—full reimbursement to living donors for lost work time, and health and life insurance for five years—has helped spur donations of kidneys, and lobes of liver and lungs. Between 2011 and 2013, the number of Israeli living organ donors increased by 67 percent over the preceding three-year period, and the Israeli transplant waiting list contracted in 2013.

It certainly hasn’t abolished the waiting list. But it’s helped. New Zealand could well save a lot of lives by following the Israeli example. Otago University hand-wringers prefer deaths to incentives; it would be nice if Parliament could pay a bit less attention to them.

Previously:

Hit the “Organ Markets” tab for all the prior posts on the topic.